Commentary on: The Influence of Age on Complications After Correction of Congenital Breast Deformities: A National Analysis of the Pediatric and Adult NSQIP Datasets

See the Original Article here. Congenital breast deformities are a class of developmental anomalies that alter the shape and appearance of the breasts. Asymmetry, underdevelopment (hypoplasia), overdevelopment (hypertrophy), tuberous breasts, and absence of breast tissue (amastia) are some of the different ways in which these abnormalities can present themselves. In comparison to other congenital defects, they are rather uncommon; however, the prevalence varies depending on the particular deformity. Significant breast asymmetry affects between 25%1 and 45%2 of women, and the psychological effects of congenital breast abnormalities can be profound. People who have these conditions may struggle with self-esteem, body image issues, and psychological distress. In this article, “The Influence of Age on Complications after Correction of Congenital Breast Deformities: A National Analysis of the Pediatric and Adult NSQIP Datasets,” Sergesketter et al aim to evaluate the impact of age on 30-day complications following reconstruction of congenital breast deformities.3 The study utilized International Classification of Diseases (ICD) codes to identify cases of congenital breast deformities in the National Quality Improvement Program (NSQIP) database across a 9-year period. Predictors of complications were identified utilizing multivariate logistic regression, and age at time of surgery was compared in these cases. The scientific background and rationale for the study were well described by the authors. Key elements of the study design were described early in the paper, such as the datasets utilized, the relevant dates, eligibility criteria, and the outcomes of interest. The authors demonstrated that correction of congenital breast deformities could be safely performed with low incidence of 30-day complication rates across all age groups. They did note a small but significant trend towards increased early complications with advancing age. Limitations of the study were appropriately addressed by the authors. Several of these require further consideration. All data for this retrospective study were generated from the NSQIP database. Although convenient for accessing large volumes of data, self-reported databases are subject to certain inherent flaws. In 2016, Gupta et al found that the ACS-NSQIP Risk Calculator (which utilizes the NSQIP database for reference) often provided inaccurate complication rates when compared to actual chart data.4 Other studies have found a higher disagreement rate between NSQIP data and chart review than the 2.5% that is described by the database.5 It should be noted that not all centers have adopted NSQIP or other quality improvement initiatives. The database includes only institutions that pay an annual fee to participate. It is less likely, therefore, to capture data from nonacademic, non–fee-for-service, or rural institutions, thus potentially reducing the generalizability of the data. The primary limitation of this article is that it is designed to look only at 30-day complication rates. Although important to acknowledge, it is not at all surprising that surgery to correct congenital breast deformities can be performed across all age groups with low early rates of complications. The most critical issue is: does age at time of surgery impact procedure-specific complications such as capsular contracture, implant malposition, fat necrosis, alteration of sensation, or difficulty with breastfeeding. As the authors point out, a balance is necessary when looking at the physical maturity of the breast and body, along with the potential psychological impact of the deformed or asymmetric breast. When correction is performed at an early age, primary drivers of reoperation relate to ongoing physical maturity and growth. This is much less likely when surgery is delayed until after the completion of puberty. Unfortunately, these most critical indications for reoperation cannot be assessed in this study. At our institution, our approach is generally to assess patients at an early developmental stage as a means to provide an accurate diagnosis, education, counselling, and guidance. In the purest of senses, it would always be best to delay corrective surgery until the completion of physical maturity. However, it is important to recognize the significant emotional and psychological impact that breast asymmetry or breast deformity can have on a teenage patient. We regularly offer surgery to teenage females in cases of significant psychological impact to at least start to address the process of correction and balancing. Techniques that can be useful in this temporizing period include the use of tissue expanders, adjustable implants, or serial fat grafting with external expansion. Definitive correction can then be performed at the time of full physical maturity. Ultimately, this study provides a basis for further examination of how age at time of surgery affects longer-term, more patient-centric outcomes in the future. This is a well-described paper which acknowledges the shortcomings of basing its design on the NSQIP dataset. Taken on its own, this article suggests that correction of congenital breast deformities at a young age has a low risk of early postoperative complications. In combination with previous evidence that these anomalies are associated with psychological distress,6 this suggests a potential rationale for early operation. This would need to be justified further with greater examination past the 30-day follow-up period. The authors declared no potential conflicts of interest with respect to the research, authorship, and publication of this article. The authors received no financial support for the research, authorship, and publication of this article.

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